3. CERTIFICATE OF COMPLETION AND COMPLIANCE.

   Certificate of Completion and Compliance

Address of premises on which land alteration was accomplished:                                                             

Inspection Date(s):                                                                                                                                  

                                                                                                 Permit Number:                                 

Relative to plans prepared by:                                                             on                              20              

                              (date)

I hereby certify that:

   1.   I am familiar with drainage requirements applicable to such land alteration (as set forth in the Code of Hancock County); and

   2.   I have personally observed the land alteration accomplished pursuant to the above referenced drainage permit; and

   3.   To the best of my knowledge, information and belief such land alteration has been performed and completed in conformity with all such drainage requirements, except

Signature:                                                                                               Date:                          20             

Typed or Printed Name:                                                                     Phone: ( ) -   

(SEAL)

                  Business Address:                                                          

   SURVEYOR      ENGINEER      ARCHITECT

            (circle one)

Indiana Registration No.